NURSES AND MIDWIVES (PAY)

HC Deb 01 July 1968 vol 767 cc1097-155

3.41 p.m.

Mr. George Lawson (Motherwell)

I beg to move, That this House, while commending the Report of the National Board for Prices and Incomes on Pay of Nurses and Midwives in the National Health Service for many of its features, nevertheless, regrets its failure to give sufficient recognition to the higher levels of qualification and skill in the nursing profession and urges that the rectification of deficiencies in this respect should be an immediate concern of Her Majesty's Government. I begin by quoting the reference in Report No. 60, which appears in the first paragraph: We were invited by the Government, as a result of joint representations by the two sides of the Nurses and Midwives Whitley Council, to examine the pay, both in terms of structure and level, and conditions of service of nursing and midwifery staff. The reference covers 300,000 lull-time and part-time hospital staff in England. Scotland and Wales and 34,000 local authority nursing staff—all the grades covered by the Council. Paragraph 2 begins by saying: The reference came to us in July 1967 …". If the Prices and Incomes Board had been more pedestrian, it would probably have made a Report merely on salary scales and conditions of employment and service, and in all probability we should not have been having this debate. But whether one says that it is to the credit or discredit of the Board, depending on one's attitude, it is true to say that the Board, in its inquiry, went further than merely to consider the wages and salary scales and conditions of employment. In effect, the Report goes into the whole field of nurse recruitment, training, classification and organisation. It is almost a complete review of the nursing services as they function within the hospital service and local government service.

The Board, in compiling its Report, did not go about its task superficially. It tells us, in paragraph 4: Our findings are based to a large extent on the results of investigations which we undertook specially, and for which we were able to secure the services of expert advisers. Detailed studies of nursing work were carried out in eleven hospitals and a survey by questionnaire was made by 587 hospitals. We therefore have a statement that the inquiries conducted by the Board were conducted under the guidance of expert advisers and that detailed examination was made into the functioning of eleven hospitals and there was a wider examination of nearly 600 hospitals. Bearing in mind that such scrutiny never seems to have been carried out before, this is a Report to which great weight might be given. Perhaps because of this there has been much concern, manifested recently, about some of the findings in the Report.

I cannot claim that I have paid particular attention to conditions in the nursing service. Some of my hon. Friends have displayed a much more aggressive interest in them than I have done. However, I find the Report valuable, first, because of the information it gives. It tells us, for example, how complex and varied the nursing service is. It tells us that there are over 200 salary scales. That is worse than the situation in the shipbuilding industry and many other industries with which we often concern ourselves. There is a wide diversity not only of salary scales, but of nursing categories.

We all know of state-registered nurses and student nurses. Perhaps not so many people are acquainted with senior enrolled nurses, enrolled nurses, pupil nurses, nursing auxiliaries and nursing assistants. Those are what might be called the basic categories. There is a whole range of additional qualifications which nurses can acquire. This is, an immensely complicated service with a great variety of skills and high levels of educational qualifications, and those in it carry a considerable measure of responsibility.

The Report is to be commended because it enables us to understand so much more fully than we might have done the complexity of the service. It also shows, if not directly, then certainly indirectly, if we are prepared to read between the lines, that there is a great range of standard in the services available to people under the National Health Service. There are hospitals ranging from the great teaching hospitals of international reputation to places of which people do not wish to know. We have different hospitals with very different standards of staffing.

It is clear from the Report that there are different standards of skill among the staff in the hospitals. I should like to quote one or two salient points in the Report. Paragraph 60 states: The level of cover by trained nurses at night is low…. At one teaching hospital which we visited it was usual to have one trained nurse and two student nurses on duty in each ward. At the most highly staffed non-teaching hospital we saw it was usual to have two student nurses in each ward and one trained nurse between two wards. At other non-teaching hospitals, staffing at night was by three student nurses between two wards (to allow for meal reliefs), and one trained nurse between five or six wards. There were even instances of patients being in danger because of inadequate or inexperienced night staff. In other parts of the Report we are told of other kinds of hospitals—such as phy-chiatric hospitals—where the staff can do no more than perform a custodial duty at night.

We see from the Report, in a way that I have not seen it before, the wide range of standards, of service and of staff, including skilled staff. We also see from the Report that there is a steady shift from the higher level of skill or qualifications to lower levels. Far be it from me to say anything that might reflect on any degree of nursing skill. All right hon. and hon. Members would agree that in our nursing profession we must have an abundance of the very highest level of nursing knowledge and skill.

We want to see progress towards higher levels in our hospitals, but we find that there is a steady shift towards lower levels of composition of the nursing staff. A bigger and bigger part is made up of the enrolled nurse, the pupil nurse training to become an enrolled nurse, the nursing auxiliary and the nursing assistant, and a smaller part is made up of the registered nurse and the student training to become a registered nurse.

I understand that the shift has been going on over many years, but to take only the three years covered by the Report, 1963–66, in England and Wales the total increase of the student registered category of nursing staff is about 1,900, or about 2.4 per cent. whereas the increase in the number of the lower skilled categories is about 16,900, just over 23 per cent. In case my hon. Friend the Under Secretary of State for Scotland smiles because he thinks that conditions are so much better in Scotland, I should tell him that over the same period the total increase in the numbers of the higher skilled categories in the profession in Scotland was 106, about half of 1 per cent., whereas the increase in the other categories was 3,330, about 31 per cent. Therefore, the shift has been greater in the smaller area than in the larger, despite the higher reputation we have in Scotland for our hospital facilities and levels of education in nursing. The number of student nurses in Scotland fell over the three-year period by about 555.

The situation in our hospital service is such that, according to paragraph 53 of the Report, The staff nurse"— that is the basic career grade, I understand, in the nursing profession— has practically disappeared from the scene in many hospitals. Paragraph 56 says, of the position in London: The shortage of trained staff is made good to some extent by the use of agency nurses. At present, in the London area they are used not merely to fill temporary gaps, but they form an important part of the permanent staff of hospitals. They account for one in seven of full-time staff nurses in the London area. The additional cost to the hospital service is considerable. I was interested to see in the Nursing Times of 21st June an advertisement by the Kent Nursing Association calling for agency nurses and offering them salaries of up to £110 a week [Laughter.]. I mean £110 a month.

I think that it is 20 years ago this week that the National Health Service was begun. It was a very great conception, and over the years it has performed immense humane services, but there should not be the wide differences in standards shown in the Report. I look with urgent concern to both my right hon. Friend the Minister of Health and my right hon. Friend the Secretary of State for Scotland for the publication of the Green Papers containing the results of the examination of the present structure and functioning of the Health Service, and their recommendations for the speedy modification or elimination of some of the worst differences of standards. I am sure that all hon. Members on both sides of the House will echo what I say about that.

The Report's main recommendations dealt with salaries and related matters. They must be very well known to all hon. Members present. The Board recommended an increase at the lower end of the scale of 14 per cent. spread over two years, tapering off to 9 per cent. at the higher levels. It recommended overtime payment for work at unpopular hours—and very unpopular hours are worked at night and at weekends, but the recommendation of time and a quarter to be paid only after a period of time, and not right away, does not strike me as particularly generous.

I know many folk in industry who would not feel very induced to work on a Staturday or Sunday for time and a quarter. The Report failed to cover all those who might be called upon to work during those periods, but I suppose that we can take the recommendation of such advances as going in the right direction.

There are recommendations for increases in certain additional payments for long-term service and service in very unattractive forms of nursing. These recommendations, while important, form quite small parts of the Report.

There are also recommendations for abolition of the broken shift system. It has been described to me, and I have had a chance to observe it, and I can well imagine how aggravating a broken shift system is to nurses who come on duty expecting to get away that evening and who are pleaded with to carry on, because of certain difficulties, and to do a working day spread over many hours. This kind of thing is always objectionable. The recommendation that the broken shift should be eliminated as speedily as possible is surely to be welcomed.

While it might be said that these recommendations constitute the principal objective which most of us suppose to be that of the Board—this is the kind of thing it was asked to look at and recommend upon—the Royal College of Nursing and the National Council of Nurses look on them with considerable reservation. In their own comment on the Report, on page 19, they say: Whilst the Council considers the recommended increase in salaries to be generally disappointing as a response to the Staff side salary claim, it accepts that these must be viewed in the context of the present financial position of the country. I am sure that my right hon. Friend the Secretary of State for Employment and Productivity would be delighted if that were the general attitude, but the fact that the Nursing Council is so moderate on this matter lends very great weight to those representations on which it is not so moderate. It is important that we recognise how moderate the Council is being in terms of the recommendations of the Board and I reiterate that this very moderation gives its views on other aspects even greater force.

The primary objection of the Council is to those recommendations which tend to circumscribe or which relate to nursing education. As the Council sees it, the Board's recommendations in relation to the longer term interests of the profession—and primarily the educational standards—point in the wrong direction. Indeed, the Council thinks that not only do the recommendations not help, but that they are positively injurious in their nature. That basic complaint, which is shared by all the nursing bodies, is a fair point to make. The Council says that it considers that the prerogative of the profession has been encroached upon by the Board's making recommendations on this matter at all.

In other words, the profession is saying politely—far more politely than many of us would have put it—that the Board should not have made recommendations on this matter at all and that such matters as nurse entry, education and training and, to use a rather harsh term, nurse utilisation, are the subject of negotiation. I hope that the overwhelming majority of hon. Members will be on the side of the nurses on this and other matters.

There is also the point concerning age of entry. The Board recommends that the age of entry into the student nursing category should be reduced from 18 in England and Wales and 17½ in Scotland. It is clear that the profession is opposed to this and I think that it is right. The valuation which we place upon ourselves is the one which most people come to accept.

This was the first profession of women in this country to achieve statutory registration. They fought for it for more than 30 years and finally got it in 1939. They were the first profession of women to say, "These are our standards. We insist upon them and we shall use the law to maintain them." In any case, a reduction in the age of entry would run counter to the whole stream of development of our society. More and more youngsters are staying on at school after the statutory leaving age. The whole idea is that they should aim for jobs with higher educational content and higher status. Yet the Board recommends reversing that process for nursing.

The attitude of the nursing organisations receives no support in the Report. For example, the present qualification for entry to the Register is two O levels and the nursing organisations want to see this raised in stages to five O levels for entry to the Register. For entry to the Roll the pupil nurse ought to have at least two O levels. The Board suggests an aptitude test for entry to the Roll and does not lay down any academic qualifications, and, rightly, the nursing associations are deeply concerned.

The Royal College of Nursing has put it to me, as it has done for years, that the entry standards should be raised. If we lower those standards we will get a lower quality of youngster into the profession. The College has for a long time sought to introduce a standard of entry requiring some five O levels. This would not be exceptional. It is normal for a whole range of new professions, many of them catering for the same kind of girl —for example, radiology. It is quite normal for such professions to require five O levels and some of them also require A levels. The nurses say they realise that their objective could not be reached at once, but they claim that it should be achieved over a period. That is why they are so opposed to the tendency of the Report to depress, instead of lift, the educational standards of nurses. The nurses do not want standards of education to be lowered.

As we all know, student nurses form a large part of the nursing staff of the hospital service. I do not like their use as cheap labour. In many ways, the approach is that the student nurse should not be described as a student, although that is not the approach of many of the best teaching hospitals. But there is no doubt that in many hospitals these girls are used primarily as cheap labour, and many do not get the training which they ought to be given.

I have had abundant evidence recently of girls being asked to take jobs with a responsibility which a second-year or third-year student ought not to be asked to accept, jobs which should be given only to the fully qualified nurse, and yet these girls are paid very much less, on average about half, than the amount paid to the registered nurse. This is the crux of the matter. It is not that nurses are sometimes treated with greater discipline than adult girls should be subjected to, or that their life outside the hospital is circumscribed. These are petty matters compared with the importance of what she is paid for the work she does, and the evidence is that far too often the young girl is treated as cheap labour with little consideration given to her training as a student nurse.

Can we be satisfied that about 70 per cent. of patient care is undertaken by students? Are we sure that it is always adequately supervised and that the student receives the education which is her due? If we are satisfied about that, are we content that she should be paid 50 per cent. of the wage payable to a registered nurse who does the same work? I have no hesitation in saying that all hon. Members would say that we are not satisfied and that this is the kind of thing which we want to be changed.

One of the things which I find particularly irksome is that these girls are described as receiving not salaries, but allowances. An allowance for a first-year nursing student, after deductions of £25 for board and lodging, works out at £370 a year. This is exactly the allowance paid to a university student living in London away from home. But the student is paid on the basis of a 30-week year, while the nurse is paid for about 50 weeks. The student gets £370, or £340 outside London, as an allowance free of tax and does not have to pay National Insurance contributions. The nurse pays both tax and National Insurance contributions, and probably one-quarter of her income goes on those items. She often does back-breaking work, although she is called a student nurse, and even in her third year her allowance works out at only about £430 —under the terms of the Report—and she then has to face these deductions.

Yesterday afternoon, I was talking to a nurse who has nearly completed her three years' training. She told me that she could not live on what she was paid. She managed only because she lived near her parents and was subsidised by them. She said that many of the girls with whom she was associated lived largely on soup as a basic diet, because they could not afford much more. I appreciate the nation's economic difficulties, but something must be done about this matter. Student nurses should be relieved of the obligation to pay tax. With any kind of justice, why should girls in one category have to pay tax when girls in the other do not? I know that this would cost a lot of money, but we are losing many of these girls from the service, and something must be done.

There is a variety of other annoyances. For example, when an increase in salary is negotiated, there is an increase in the amount which has to be paid for board and lodgings. This is a proportionate increase. The girl to whom I was talking yesterday said that she had had £10 retrospective payment, of which about £6 10s. had been used to pay an examination fee and she had used the rest to buy books. She said that some of her colleagues had been left with only £2 or £3, because they lived in. Is there any justification for this proportionate increase, difficult though the nation's financial position may be?

More especially, the charge for board and lodgings is the same irrespective of the quality of the board and lodgings. The charge is not related to whether the girl has a bedroom of her own. She may be sharing a bedroom, or be in a dormitory, or be sharing toilet facilities with others, or she may have a nice bedroom, according to the hospital, but, according to her status and according to what she is receiving, so she pays. I am sure that my right hon. Friend cannot justify that. Perhaps he does not know that it goes on, but I am now shouting in his ear that this type of thing is the cause of so much ill-feeling and should be ended. If there has to be a charge, it should be commensurate with what is obtained and should not be fixed irrespective of the kind of service provided.

Another difficulty is that a girl who has completed her training as a registered nurse and who then decides to become a midwife may suffer a fall in salary of £151, plus £36 which she would have been getting if she had continued as a registered nurse, making a total of £187 in her first year of midwifery training. If she were an ordinary student who had decided to take another course, it could be argued that she had chosen to do so, but one such girl is acting in a large maternity hospital as an equivalent to the ward sister. She is a trained nurse and her duties are so arranged that when the ward sister is off, she is on. She is giving trained service for a salary which, she tells me, the domestic worker is getting for a 20-hour week. That kind of thing is bound to break anybody's heart.

There is a feeling of wrong and injury. My right hon. Friend should look at this and consider what he can do. There is great concern about educational standards, and he should pay great attention to what the nursing profession says. It is concerned with the standards and quality of nursing, and when it gives advice in terms of nurse training, the kind of organisation there ought to be for training nurses, then he should pay great heed to it. The Report says that the Board's recommendation in this connection is for larger grouping of our nursing schools, which shows very little concern for the quality of the education given to the girls. At bottom, what the Board is recommending is a better pooling system of junior nursing labour, where they can be more efficiently employed over the hospitals in a given area. If that is how the recommendations would work, then the profession would be utterly opposed to it.

I am fortified in my belief in this respect by the attitude displayed in the Report towards the tutor nurse. I understand that it can take eight years to train a tutor nurse, and that she will normally go to university for two years, yet she is lowly graded and lowly regarded, in the Report and the Health Service. An examination made into this in 1966 showed that 44 schools of nursing were in the charge of unqualified nurses. My hon. Friend the Parliamentary Secretary has earned some ill-repute, undeserved in many other respects, by a remark to the effect that they were skilled nurses and unqualified tutors. Of course they are, but they are not skilled tutors.

To take a comment made by the Board in its Report concerning tutors. The Board was discussing the question of student wastage. The General Nursing Council for England and Wales recommended that one way of countering student wastage was by paying the tutor a higher salary. The Board comments: We are not pursuaded, however, that increasing the pay of those who teach will by itself do much towards preventing the wastage of those who are taught. That is a dreadful and shameful statement. Anyone who knows anything about teaching, or who has been taught —and we have all been taught in some way or other—knows how immense is the difference between teachers. We can be stimulated by some and depressed by others. Many of our student nurses are being taught by unqualified, uninspiring nurses, whom they can perhaps see are not fit to teach and we are bound to have this wastage. A girl wants to be taught to become skilled as quickly as possible, and if she finds that the person responsible for teaching her cannot give her this knowledge, she will leave. On this basis, it is very important that the tutors be regarded highly. I see you straining at the leash, Mr. Speaker, so I will draw quickly to a conclusion.

Figures have been given which show a steady decline in the number of qualified tutors. We have almost no qualified or registered qualified tutors under the age of 30. The bulk of them are between the ages of 50 and 60. This means that the tutor is passing out; there are no fresh entrants. On this basis, there is a powerful argument for dealing with this problem. There are certain meannesses in the Service, not just the hospital service, which I would like to see examined.

In most cases the district nurse is treated very meanly. She has a substantially smaller salary than the ward sister, with whom she is comparable in terms of skill. In many cases she is better qualified than many ward sisters. She has a salary which, at its minimum, is more than £100 less than the ward sister. Often she has to have a telephone and a motor car—although I have seen district nurses standing in a queue waiting for a bus, which is not an efficient use of labour. When she has a car and telephone, these are taken as part of her wages, which is absurd. We should treat these women, performing this valuable service, in a much better way.

If the nursing profession is to regain its former status—although it still retains that in our minds—the very top people in the profession must be adequately rewarded. If there is to be room for proper differentiation of rewards for the varieties of skills and responsibilities this is vital. The nursing profession is adamant that what is offered is far too small—it is about £3,000. The Salmon Recommendations for the reorganisation of the service takes the top person in the profession and says that they are worth only £2,295.

The nursing profession says, and it has reached this conclusion after having examined many like jobs, that the very lowest at which the top salary should be reckoned, is £4,500. It does not say that there are thousands of women who will get this, but that it is a gradual process of establishing posts. It says that where and when they are established, the top person should be put on that level. Sub-sequently, that will leave room for the proper adjustment of the other scales. These are my proposals, the views I have reached as a result of a careful study of this report, which I would not have undertaken had I not been successful in the Ballot. I am sure that all hon. Members will thoroughly support my Motion.

Mr. Speaker

May I remind the House that this debate finishes at 7 o'clock, and that many hon. and right hon. Members wish to speak. Reasonably brief speeches will help.

May I also announce that I have had a report on the state of the atmosphere in the Chamber. I am informed that the air conditioning plant is designed to reduce the outside temperature by 10 degrees and that at the moment the outside temperature is 88 degrees. The engineers have managed to get the temperature of the Chamber down to 73 degrees, which is 15 degrees below the outside temperature. They are still continuing to do the best that they can.

4.30 p.m.

Sir John Vaughan-Morgan (Reigate)

The hon. Member for Motherwell (Mr. Lawson) has done a considerable service in bringing this matter before the House at this stage. No one can say that his speech in any way raised the temperature of the Chamber and I shall endeavour to follow suit. The hon. Member gave a comprehensive review of the problems of the Report and in obedience to your wishes, Mr. Speaker, I shall try to be very brief. I disagree violently with him on one point, but I will refrain saying anything on that at this moment.

As I understand, the Minister will wind up the debate. That places me in a little difficulty, because I should like to have known exactly how far he has got in his consideration of the Report. I understand that the Report will now go back to the Whitley Council for consideration. The other suggestions in the Report will no doubt be chewed over by those concerned. I think that the Minister would agree that it will do no harm for him to have a few warning shots across his bows as to the bits of the Report which I believe will be unacceptable to almost anybody at this stage in the proceedings.

I wish to voice the concern felt in many quarters, not only by the Royal College of Nursing, at some of the recommendations contained in the Report. I think that one needs to look at the Prices and Incomes Board first. There is its Report No. 60. That is a remarkable output for a comparatively short life. The matter was referred to it in June, and it reported in March—nine months. The 14 wise men and women who composed the Board have found it possible to resolve problems that have worried many more expert people for many years. As a result of visiting about 15 hospitals and the answers to some questionnaires, it has not hesitated to make the most fundamental and far-reaching recommendations, some of which go far beyond any concern with the pay of nurses and midwives.

To give an example in paragraph 157 the Board comes out with a suggestion for area hospital boards. I take it that it has read and digested the Porritt Report. There may be a great deal to be said for this, but, to my mind, when the Minister is considering the matter and about to produce his Green Paper I hope we can take it that he will give the matter rather more than nine months consideration before he comes down so categorically on the side of a very fundamental change in the structure of the National Health Service.

I find it extraordinary that anybody can come forward with some of these recommendations on the basis of such very short experience. Many other of the suggestions are equally superficial. For example, the suggestion that the grading structure put forward in the Salmon Report, except for Grade 10, should be introduced on 1st January is ridiculous. I think that it took the Salmon Committee two years to report and produce a very well-thought-out scheme which the Minister has accepted in principle, and it is now being tried out experimentally in one or two places. This is right. But for this body to come forward and say that it can all be done within a matter of a few weeks, is puerile.

In any case, it is starting at the wrong end. The first matter to be implemented is at the top. The first thing to do is to appoint the Chief Nursing Officer. With her experience and wisdom she can get the Salmon structure going from above. So I hope that that recommendation will be totally disregarded.

Understandably, most of the Report is concerned with matters of pay. I do not want to burden the House with too many detailed comments and my own views about what is good and bad in the recommendations. But there is one choice comment in the Report where the Board says in paragraph 159: we think first that the largest increases in pay should be concentrated where shortages are most serious ". To me, that is a blinding glimpse of the obvious. I cannot think of a better reason for giving the increases in pay, but one must be frank and say that that is not consistent with the Board's attitude throughout.

For example, this principle, which, in my view, is right, is not to be allowed to apply in the case of qualified tutors, a point which the hon. Member for Motherwell dwelt on at some length. He was right to do so. It shows an admission that there is a general shortage of tutors. If there is a shortage of tutors there will be a shortage of nurses, particularly of good nurses. Recommendations such as this are calculated to discourage those who are qualified to move into the sphere of nursing education.

There are many other points that I could bring forward, but I leave them to my hon. Friends and hon. Members opposite to speak about. I want to raise one more fundamental principle which perhaps goes even wider than some of the terms of the Motion, and that is the question whether the Whitley machine is the right one to deal with the question of nurses' pay.

The matter of nurses' pay has been taken out of their hands for the moment and put in the hands of the Prices and Incomes Board, and now it goes back to the Whitley machinery, for ultimate decision, presumably, by the Minister. This is a bee in my bonnet which does not have many opportunities of buzzing around. I do not know whether we ought not to take a leaf out of the book of the doctors and dentists and institute a review body. The Whitley machine is something of a sacred cow. Very few people like to criticise it, but it is appallingly slow and cumbersome. The doctors and dentists have opted out of the Whitley machinery, and I think that the time has now come to create a similar body for nurses and midwives and another review body for the other grades in the National Health Service.

The fact is that within the nursing ranks shortages occur, but a shortage cannot be met without consideration of both sides in the Whitley machinery and the appallingly long procedures that are gone through. Outside the nursing grades and the doctors, sometimes the work is held up because there is a shortage in a particular grade, such as pharmacists, who were mentioned. Sometimes it is even telephonists, a shortage which can cause the whole work of a hospital to be threatened. At the moment, it is a shortage of medical secretaries in the big cities which is jeopardising the work of many of the big hospitals. Nothing can be done about it. It is all under consideration by the Whitley Council. Then, at long last, the increase or change in grading, or whatever it may be, goes forward, and ultimately the shortages are made good, but by then a lot of valuable time has been lost.

Although I do not ask the Minister to pronounce on what would be an even more fundamental change today, I hope that he will give this his consideration and try in that way to resolve one of the most difficult problems in the National Health Service.

4.39 p.m.

Miss Margaret Herbison (Lanarkshire, North)

I should like, first, to congratu- late my hon. Friend the Member for Motherwell (Mr. Lawson) upon choosing this important subject for a debate. I think that all hon. Members who are in the Chamber would like to congratulate him on the way in which he has dealt with it.

We had an Adjournment debate on this subject, initiated by my hon. Friend the Member for Fife, West (Mr. William Hamilton), and on that occasion the Under-Secretary of State for Scotland made certain pronouncements. He told us that recommendations of Report No. 60 of the Prices and Incomes Board on salaries had been accepted, but that the recommendations concerning training, age of entry and other matters had not necessarily been accepted. It is important that we should know this, and it is of great importance today that my right hon. Friends the Minister of Health and the Secretary of State for Scotland should have the views of hon. Members on vital matters such as training which have been raised by my hon. Friend.

Both sides of the House are critical of some of the recommendations in the Report of the Prices and Incomes Board, but before I go further I feel that the Government deserve some credit for the way in which they have handled, in the first instance, the salary awards which were made. There has been criticism, but, at least, the 4 per cent. has been paid and it has been made retrospective. Those in psychiatric hospitals and those who look after the old people and the chronic sick have also had the increased lead in salary which was proposed in the Report.

We in this House have a great responsibility towards nurses. I remember the debate which continued throughout the night when I sat on the benches opposite, when time and time again it was stated that because of the devotion of nurses to their work and because of their attitude towards their patients, they would not strike. Even at that time, when they were so shabbily treated, they neither went on strike nor threatened to strike.

We simply cannot take that devotion for granted. When nurses show that very great sense of responsibility, there is an even greater responsibility on Ministers of the Crown and on ordinary Members of Parliament, on both sides of the House, to ensure that nurses, their conditions of service and their salaries are given far more attention than they might otherwise be given.

I wish to look first at a point touched on by my hon. Friend concerning the very great wastage of nurses who go into training. I understand that of every 100 young girls who are attracted to nursing, 30 per cent. fall out before they have completed their training. I do not know whether the Government—the present or previous Governments—have investigated as thoroughly as they should the reason for this great wastage of those young women who, in the first instance, have been attracted to nursing. One of the reasons might be the inadequacy of their pay.

I said that the Government could take some credit for what they had already done as a result of the Report, but when I look at the payment of nurses and at the payment of benefits to other people for whom I was responsible for almost three years, I have to say to myself that this is a 4 per cent., 12 per cent., or 20 per cent. increase—on what? In other words, was what the nurses—or, for that matter, our old people—had previously an adequate sum? The answer of all us must be that it was not adequate. Therefore, whatever consideration the Government give to this matter, they must begin from the premise that never in our history have our nurses been adequately paid.

I met a representative group of nurses from the County of Lanark. Like my hon. Friend, who met them at another time, I was greatly impressed by the case that the nurses made to me. I was greatly impressed by the temperate manner in which they made it. I would give them full marks for not being extravagant in their actions or in their claims. The Report from the Royal College of Nursing dealing with the Prices and Incomes Board Report No. 60 takes into account the financial circumstances of the country, and this fact was remarked upon to me by the group of nurses whom I met. In other words, we are not dealing with a group of hotheaded people who want something irrespective of whether the country can afford it. It is, again, because of that attitude of the nurses generally, whether they be in the Royal College of Nursing or in the trade unions, that there is an added responsibility upon us as Members of Parliament to ensure that they get fair play.

In moving the Motion, my hon. Friend the Member for Motherwell dealt with some very wide issues. I should like to deal with a number, but I will deal with only two. The first is the question of training and how tutors are affected by the Report which has been published and the fears of the nursing profession if the Government in their wisdom, after consideration, finally accept its proposals.

Like my hon. Friend, as a result of this debate I have obtained a great deal of information. Any nurse who wants to become a registered tutor must have high qualifications. First, she must have what the nurses call eight years of preparation to start with. Before she is accepted for the two years' training in a university course, she must have the entrance qualifications for the university. These are no mean qualifications that we are asking of those who are to perform the vital job of training and tutoring young nurses. The extra reward which they now get, or even the extra reward which is proposed in the Report, either in salary or in promotion prospects, is so little that I believe, as do the nurses, that there is very little incentive indeed for them to undertake that great extra preparation.

Let us look at the figures. A registered nurse tutor gets £1,232. We find in the profession that even those who have taken the training and who are registered nurse tutors are being attracted into other forms of teaching. As an example, from the County of Lanark, a man who was receiving his £1,232 obtained a post in a college of technology and his salary immediately jumped to £2,300. How are we to keep those tutors in the nursing profession, where they are so vitally needed, if that is the position in which they find themselves at the present time?

I turn now to clinical instructors, who must have at least seven years' preparation plus a six months' course at a training college. After the six months' course, one would have thought that they would be able to look forward to some extra financial reward, but, not a bit of it. After that extra training, there is no additional financial reward. All of this is reflected in the shortage of registered nurse tutors and clinical instructors.

If one looks at the ages of tutors and clinical instructors one finds that the vast majority of them are over 50 years of age. That again is very serious, because it means, in effect, that when they come to the point of retirement there are no younger ones ready to step in and take their places.

I have been given some figures for Scotland. In August, 1967, there were 102 nurses doing this vital work of tutoring without the necessary qualifications. Even worse than that, there were 96 vacant posts in Scotland alone. This must be a great cause for concern not only for the nursing profession, but for the two responsible Ministers and all hon. Members. We must always link this position with the care and the safety of patients. They must not be forgotten. It must also be linked to whether our young nurses are getting adequate training.

I can think of nothing which would lead to more wastage among young nurses than the feeling that they are in a job, being used as cheap labour, and are not receiving the training which will make them responsible people in their chosen profession. I am afraid that that is happening today in some instances.

I had intended to say quite a bit about midwifery tutors. I have some information before me which my hon. Friend the Under-Secretary of State may have already. If he has not got it, I will gladly send it to him. My hon. Friend the Member for Motherwell also dealt with this point.

Looking again at wastage, it must be remembered that the young woman who is to be trained in midwifery is a State-registered nurse. However, when she takes her training in midwifery, immediately her salary drops, in spite of the additional training that she has undergone to care for our mothers and children.

In Scotland, of those trained in midwifery between March, 1966, and February, 1967, 10.6 per cent. went overseas. In the period from March to November, 1967, that percentage increased to 16.6, and in case anyone thinks that included in that percentage there are a number of young coloured nurses who have come here for training I would stress that the figure is exclusive of those who have returned to their own countries.

The second aspect deals with nurses employed by local authorities. Those whom I met felt that the section of the Report dealing with them had much to recommend it, and I learn that my own County of Lanark has already implemented some of the Report's proposals.

There are a number of matters which must be a source of worry for most people concerned with the domiciliary services. First, there is a real shortage of experienced administrators in the service. Again, this is not surprising when one looks at the facts and realises that the salary of an assistant nursing officer is only £36 a year above that of field staff and that no living accommodation is supplied for such a person. I feel strongly that it is because of the lack of incentives that most nurses in the field do not seek promotion. Who will seek promotion to take on heavier responsibilities with no incentive to do so?

Turning to those who are actually doing the work of caring for patients in their own homes, we find that district nurses are still paid £110 a year less than ward sisters. I would be the last to say that ward sisters do not carry a great responsibility, but I feel that district nurses carry at least as much. I have had experience of a district nurse in my home and I can speak almost from the heart about the kind of work that they do for our old people. So often old people are able to stay in their own homes when otherwise they might be taking a bed in a hospital.

My hon. Friend the Under-Secretary of State has already had a meeting with Scottish representatives of the Royal College of Nursing, and I know that he has promised to meet them again at the end of the year. I urge him and my right hon. Friend the Minister of Health to give serious consideration to the case made to them by the nursing profession on such matters as education and all that is bound up in it. I know, too, that they will give great consideration to what is said today. Even in a profession of mainly dedicated people, promotion prospects are important. Training is also important, both for the nurse who wishes to know that she is on top of her job and for the care of the patient.

I congratulate our Government on what they have done already, and I urge them to give the gravest consideration to the points made today.

4.58 p.m.

Mrs. Jill Knight (Birmingham, Edgbaston)

To understand the attitude of our nurses, it is necessary to look at the frame of mind in which they awaited Report No. 60 from the National Board for Prices and Incomes on the Pay of Nurses and Midwives. This was the first: time for 20 years that a chance had been taken to examine in depth the problems facing the nursing service. Incidentally, it is 20 years ago that the National Health Service first began. In all that time there has not been an examination such as this was to have been. For that reason, the nurses were extremely anxious and awaited with great eagerness to see what the Report said.

There was the chance to dissect and examine the whole suffering of the valiant nursing service and prescribe some sort of remedy. The scalpel of the National Board for Prices and Incomes probed, the stethoscope roamed about the affected area, temperatures and blood counts were taken, and, finally, the surgeon threw all the suggested modern remedies out of the window and bled the patient.

Because of the attitude shown by Report No. 60, there is widespread frustration and dismay in the nursing profession. It is true that the Report suggests that starting salaries should be raised, but it does not make the same proposal for concluding salaries for those at the peak of the profession. A nurse constituent of mine, who has a gift for a turn of phrase, has written to me saying, "This has resulted in a sliding scale resembling a deflated concertina". Attracting women and, indeed, men into the nursing profession is not just a matter of starting salary. The salary scale at the top level must be adequate.

I want to make three points briefly about the future. They have been mentioned by other hon. Members, but, as the right hon. Lady the Member for Lanarkshire, North (Miss Herbison) said, this is an extremely important matter because there is a grave shortage of hospital tutors. The Minister of Health ought to accept that the ratio of one tutor to 40 students is too big. The Royal College of Nursing suggests that it should be one to 30 for general nursing students and one to 20 for students in psychiatric nursing. That is very important.

The grading proposals of Report No. 60 for hospital tutors was extremely disappointing. In Appendix XI on page 66 of the Report, the Board suggests how the different grades might fit into the new grading structure which is so important in attracting people into this branch. The Board suggests that tutors should be in Grade 7 and principal tutors in Grade 8, and in the body of the Report reference is made to the principal tutor in a very large group school being in Grade 9. What does this mean, and in which group will they finish?

One most important point about tutors is that when they have finished their training they are qualified to teach certain subjects in colleges of further education. If they opt to do that, they get far more money than if they opt to be a hospital tutor. I do not know whether the Minister of Health is on speaking terms with his right hon. Friend the Secretary of State for Education and Science, but it would be helpful if they got together and made up their minds that the colleges of further education should not attract these people from the hospital service where they are desperately needed.

The hon. Member for Motherwell (Mr. Lawson) spoke of student nurses taking a drop in salary, after they have become S.R.N., when they opt to take midwifery courses. If he proposes to take the point up with his right hon. Friend, I must tell him that he will not get very far, because I took it up with him more than a year ago, and when I explained the case of a constituent who had suffered a similar drop in salary, the only reply which I received from the Ministry was that there was no shortage of midwives anyway, so why should anyone be concerned about it?

It is most important that hon. Members on both sides of the House should attempt to explain to the Minister the frustration felt by nurses. One of them wrote to me about Report No. 60 explaining exactly how she and her colleagues feel about it. I sent the letter to the Minister for comment. After a short time I received a reply, not from the Minister but from the Parliamentary Private Secretary, stating that this was a matter for the Whitley Council and that my constituent was advised to make her views known to her staff organisation.

This constituent is a member of the sub-committee of the Royal College of Nursing responsible for the comments on Report No. 60, and her views and those of her colleagues are very well known indeed to her staff organisation. Having submitted her comments on the Report, and having made her views known to the staff organisation, she thought that the next step was to contact her Member of Parliament to make sure that the Minister knew these views. When she did so, she was pushed back again to the bottom of the ladder and told to contact the Whitley Council.

Mr. William Molloy (Ealing, North)

Is not the hon. Lady aware that this kind of recommendation and protest has been going on for the past 20 years, but that nothing happened about it from 1948 until this year?

Mrs. Knight

As far as I can see, nothing much will happen now unless many hon. Members press very hard for some action. The point which I am trying to make is that it is excessively frustrating for people who have already done all the things which they should do through their staff organisations and who then seek to contact the Minister through their own Member of Parliament, to find themselves once more at the bottom of the ladder. I do not care how long this has gone on. It is high time that it was stopped.

It is not just a matter of pay. There are many other causes of frustration and worry in the nursing service. They have clearly shown their reaction to Report No. 60. For example, there is the point about the varied educational standard. The hon. Member for Motherwell, too, raised that most important point. I understand that they want older candidates with acceptable qualifications to be admitted for training as nurses and that, too, is important. The working of the shift system is another point for consideration. I could mention many other issues but I will not go into them deeply because other hon. Members wish to take part in the debate.

All these problems, and many others which could be mentioned, add up to the biggest total of discontent the nursing profession has had for a very long time. The right hon. Lady was right to say that the responsibility is on all of us to see that these pleas are heard. These are not railway workers, or airline pilots, or sewing machine operatives. For that reason, among others, their pleas ought to be heard, and I earnestly hope that they will be heard.

5.8 p.m.

Mr. Kenneth Lomas (Huddersfield. West)

When I entered the Chamber I made two promises to myself. The first was to be brief—a promise I intend to honour. The second was—for a change— not to be political. But the speech of the hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight) sorely tempts me to break that promise because it seemed to me to accuse hon. Members on this side of the House of not holding an examination into this problem of nurses' pay. That was one. of the most unfair statements which I have ever heard in this House. We have had only three years of the last 20—the three years since 1964—to do that. I hope that it is recognised by the hon. Lady and her hon. Friends that the Government were right in setting up the National Board for Prices and Incomes and certainly right in referring the whole question of the pay of nurses and mid-wives to the Board for the Report— Report No. 60—which the Board has now presented.

But I promise to be brief, and I will therefore come to the points which I want to raise. I am sure that the House agrees that the speech of my hon. Friend the Member for Motherwell (Mr. Lawson) needs to be read in depth. It showed that he has given very careful consideration to the whole of the Report. I hope that he will understand if I do not touch on the points which he raised but deal with other aspects of the Report. Before coming into the House, for 10 years I was an employee in the Health Service, and I am a Member of Parliament sponsored by the National Union of Public Employees which, I remind my right hon. Friend the Member for Lanarkshire, North (Miss Herbison) also represents nurses. It is not only C.O.H.S.E. who recruit nurses. The National Union of Public Employees has a very large number of nurses in its ranks.

It is fair to say that much of the Board's Report on the question of hospital efficiency and productivity confirms the view which my union and I have held for some time about the need to improve the quality of the hospital service by raising the level of management efficiency and, of staff productivity. Paragraph 157 of Report No. 60 says: We think that there is a diffusion of authority and a fragmented system of management which makes it difficult to increase efficiency in the hospital. That paragraph goes on to …suggest that in the long term the present system might give way to a single tier system in which authority and management functions would be concentrated in a small number of Area Health Boards or similar bodies. It might be said that matters like this should be left until the Minister has produced his Green Paper and the matter has been argued and discussed. But the Board went into this matter very thoroughly and came up with ideas which conform very much to those which my union has expressed on many occasions.

We have taken the view that area health boards might well have similar boundaries to the revised local authority boundaries which might be recommended by the Royal Commission on Local Government. Such area boards could integrate the three existing wings of the National Health Service; the hospital service, the local authority service and the executive council service. The sooner we get everything under one umbrella, the better the Health Service will be in every possible respect. It will be possible, once we have done that, to create and be responsible for an occupational Health Service which is long overdue.

In paragraph 158 the Board points out that: Immediate steps are needed and are possible to increase efficiency. Within the hospitals there are great differences in efficiency …". The Report points out that these differences in efficiency occur … whether this is considered in terms of the use of available staff, unit costs, or ward routine generally. These views reiterate what was said by the Board in Report No. 29, which was concerned with manual workers in the Health Service. They underline the fact that this matter is of consequence not only to nurses and midwives but to the whole of the Service and that the matter must be looked at in that context.

In this light we must try to understand that if the efficiency of the nursing services is to be improved, there must be an opportunity to plan and implement changes in working practices which could be reflected in terms of pay and conditions. This is exactly what the Board said when it referred to ancillary workers in Report No. 29. I hope that we will see these recommendations implemented to that it will be possible to introduce work study and incentive payments schemes and productivity bargaining.

For a considerable time my union has been raising these matters and has been trying to make hospital managements conscious of the need to raise productivity and efficiency. However, the process has been slow and difficult and a great deal more pressure is needed at Government level if hospital management committees and regional hospital boards are to understand how imperative it is to achieve our main objective of linking improved pay with improved productivity.

There has been criticism of the pay awards suggested by the Board. We are, of course, never satisfied with what nurses get because they perform a service which cannot be measured in £ s. d. In view of the general economic condition of the country, my union believes that the award is about as fair as one could expect in present conditions. We welcome the increase from £50 to £100 in the mental level for all grades in pyschiatric hospitals, as well as the payment, for the first time, of £100 as an allowance to all grades in geriatric and long-stay hospitals.. This is a welcome decision, which is long overdue. We also welcome the recommendations for extending overtime payments to all grades in psychiatric hospitals up to and including the level of ward sister and charge nurse.

However, the two major issues in Report No. 60 which fall short of the ex-pectations of my union are those which reject the claims made by the unions for a shorter working week and for the general application of overtime pay to all grades of nurses. There is no doubt that nurses work a longer week than any other staff inside the hospital service. While recognising this, the Board says that the working week of nurses is shorter than that of some occupations outside the Service. Unfortunately the Board does not substantiate that claim.

It is recognised that the vast majority of workers today enjoy a basic 40-hour week, and not the 42-hour week of the nurses. Apart from the injustice of nurses working different hours from other hospital workers inside the same institutionalised unit, there is an element of unfairness in this. It is fatuous to say that because a small minority of workers outside hospitals still work more than 40 hours as a basic working week—I grant that that applies in a few instances, such as in catering and agriculture—nurses should be deprived of what is an almost universally accepted right, and I hope that the Government will consider the matter further.

On the question of overtime, the Board says that a recent Ministry of Health survey showed that little overtime was being worked at present in general hospitals and that this indicated that there was no general staff shortage. In consequence, it recommends against the introduction of overtime pay. This is a peculiar argument, because if no overtime is being worked, the concession of making payments for overtime could be introduced without involving the Service in any significant increased cost. It is a harsh message to tell nurses that they must establish a general staff shortage before they can be paid for the overtime they are working. This is an Alice in Wonderland attitude which must be changed. Overtime is a very personal thing to the individual and for nurses to be treated differently from virtually every other grade in the hospital is a serious anomaly which must be put right.

The recommendations of the Board on payments for night and weekend work appear in paragraph 160 (iii) and are an improvement on the present position. However, they fall far short of the provisions that are usually made for workers who are required to be on duty at the most inconvenient hours. For example, ancillary grades working in the same hospital as nurses receive time and a quarter for night duty whereas nurses get time and one tenth. For Saturday afternoon duty, ancillary grades receive time and a half while nurses get time and a quarter. For Sundays, ancillary grades get double time while nurses get time and a quarter. This division of payment and division of staff does not create the harmonious hospital service we want, and the Government must look at it.

In the general sense, the Board's recommendations tend to undermine the existing position in the hospital service, since the large body of workers on duty at night and weekends are nurses and ancillary staffs and, in particular instances, the premium payments proposed are less favourable than those already applying to nursing staff on special duty allowance arrangements.

An interesting comment in paragraph 54 of the Report is that hospitals are forced to use agency nurses to fill the gaps left by the shortage of staff nurses. The Board says that more than 1,300 agency nurses were employed in hospitals in July, 1967—most of them in the London area. My union has continually complained about the practice of hospitals employing agency staff, not only in the nursing but in the domestic, professional and technical grades. It has a very serious effect on staff morale when it is known that agency nurses are being paid much more than the hospital nurses. That seems to be quite wrong. Equally, it tends to give a false picture of genuine staff shortages, which can only be remedied in the true sense by improving the pay and conditions of those who work in the hospital services.

I welcome the Report. It has some faults, but much of what it says is good. The Government intend to act on many of the recommendations, and we should indeed be glad that the Government referred the whole question to the Board. The Report calls for action, and the action must be taken in a fairly short space of time, because we have a great problem in making sure that we hold our nursing staff, improve the quality, and get the numbers that are so badly needed.

One fact must be clearly understood by nurses and by anyone else in the National Health Service. The advances that have been recommended by the Prices and Incomes Board have not been handed to the nursing profession, or to the ancil-laries or to anyone else on a plate. They are the direct result of negotiations that have taken place by the trade unions, and of the pressures that have been brought to bear on management and the Government by the unions in order to persuade them that these things should be very carefully considered.

The lesson that the nurses, above all, should take to heart is that they must no longer rely upon the sympathy and the understanding of the general public. They must realise that if they are to make progress they must unite in a militant organisation that is recognised and one that can push their claims straight to Government level and argue the case forcefully on their behalf. If the nurses want to see an improvement in their pay and conditions, and if they want to go from strength to strength, my advice is. that their best course of action is to join a union, and in particular my union—the National Union of Public Employees.

5.24 p.m.

Mr. Cordon Campbell (Moray and Nairn)

I congratulate the hon. Member for Motherwell (Mr. Lawson) on his success in the Ballot and on having selected this subject for two main reasons. First, the question of nurses' pay is very topical, in view of the recent Report of the Prices and Incomes Board, which has made an examination of the whole structure of the professions involved, and, secondly, because these professions are an essential part of our country's services for healing and the care of the sick.

I do not have any close connection with our medical services: my experience is mainly having spent a year as a patient in a well-known teaching hospital at the end of the war. That inspired in me a great admiration for the nursing profession, as I think it would in anyone who had a similar experience. It is clear that nursing is a vocation and a profession with high standards and fine traditions, and when pay and conditions are being considered we must be careful to preserve these.

I intend to raise two main points. First, the position of qualified tutors has already been raised and in the course of my remarks I shall wish to say more on that subject, especially because the Report draws attention to some of the deficiencies in the present system but does little towards remedying them. My other point will relate to gradings, and to the salary ceiling that is proposed. I shall seek information from the Ministers concerned about their plans for grading, and I shall also wish to query the salary ceiling.

Nurse tutors have to undergo an arduous two-year course after some years of previous training. They then have the responsibility of teaching student and pupil nurses. Upon their teaching will depend the flow of large numbers of trained nurses, and on them also will depend the interest of those nurses in their profession, and their knowledge and efficiency.

In page 44 of its Report, the Board says: Our main conclusion on training was that a high priority should be given to setting up larger training schools, independent of the nursing management of particular hospitals. This would ensure both better use of tutorial staff, and a better organised and more worthwhile training programme for student and pupil nurses. The Board clearly regards training as important. It has drawn attention to some of the deficiencies, but says nothing to encourage those who are already teachers and those planning to be tutors.

Appendix XI, on page 66, proposes that for salary the tutor should be in Grade 7 and the principal tutor in Grade 8. That clearly does not put them high enough in relation to other categories. There is already a tendency for potential tutors and registered tutors to go into administrative posts, where their pay is better. That tendency is likely to get worse if these recommendations are followed. I think it was the Nursing Times of 21st June which gave an example of 96 tutors who recently left teaching in schools of nursing. It was found that 90 of them are now receiving a salary greater than that of a principal tutor, to which position they would otherwise have expected to graduate.

There is, therefore, this financial temptation to move into administrative or other jobs. The Report of the Prices and Incomes Board admits that more registered tutors are needed. I hope that while the Ministers will find that parts of the Report can be accepted, they will very seriously examine the teaching side, and the position of nurse tutors and principal tutors, because these proposals will do nothing to help fill the gaps that are there already or deal with a situation that is likely to grow worse.

My second point relates to grading. If the Report of the Salmon Committee is implemented on 1st January, 1969, certain questions arise. Will the nurses in hospitals be allocated to the various grades suggested in the Report? Will hospital staffs be reorganised into these grades? I seek information because it is not clear to me whether the Government will encourage this.

I agree with those who have said that a salary ceiling of less than £3,000 for the very highest post in the profession is the wrong way to deal with this matter. I hope that this will be re-considered, because those who occupy these very few responsible posts at the top of the profession carry very great responsibilities. It will not encourage an intake of responsible people into the profession if a ceiling of this kind is imposed. Not only that, but the ceiling at the top governs the salaries of all those below. I hope that the Government will not follow this recommendation and will discard the proposal to proceed by way of setting an inadequate and unambitious ceiling.

I have kept to these two points, which I think are most important. There are many other things that I and others could say about the Report. I hope that the responsible Ministers will take special account of these two points.

5.31 p.m.

Mr. William Hamilton (Fife, West)

The whole House and the country owes my hon. Friend the Member for Mother-well (Mr. Lawson) a deep debt of gratitude for giving us an all too infrequent opportunity to discuss what I think is the noblest profession in the world. I say that partly because I married one member of the profession and produced another. Therefore, I have always had an interest in the profession, partly from the materialistic point of view, but also because I have always felt that it was, in addition to being the most noble profession, the most grossly exploited one.

The debate has spent a disproportionate amount of time on highlighting the shortcomings of the Report, the anomalies and the injustices. It is right to put on record what the recommendations will cost when implemented. Paragraph 143 gives the figures—£201 million for the United Kingdom hospital service, £33.5 million in local authority services; the 9 per cent. increase will amount to £17 million; the overtime in the two stages together will account for over £14 million. So there are substantial increases.

When the right hon. and learned Member for Wirral (Mr. Selwyn Lloyd) was Chancellor and sought to impose a prices and incomes policy, he selected the nurses for a freeze. We fought this in the House. The right hon. and learned Gentleman said, "Whatever happens to other sections of the community, the nurses shall get nothing". I remember appearing on the platform with the hon. Member for Fife, East (Sir J. Gilmour). The nurses were more militant then than they ever were before and are ever likely to be in the future, as a direct result of the attitude of the then Conservative Government. We should get this problem into some kind of perspective.

The Report can be criticised to some degree in that it pays rather too much attention to the numerical quantity of nurses that we require, rather than to the quality of nurses. Since the National Health Service was inaugurated, there have been enormous developments in medical science and knowledge. This must mean an increasingly high quality of nursing labour in the hospital service. This highlights a problem which has quite properly been emphasised in the debate, namely, the need to increase and improve the quality of nursing education and to ensure an adequate supply of highly-qualified teaching staff.

It has been pointed out repeatedly that the Report recommends no incentive to ensure that this will happen. On the contrary, there are some contradictions in it. The Board says that the age of entry should be lowered, but it does not say where we shall get the increasing numbers of tutors to train the increased number of nurses. If this recommendation is accepted, the position qua training will be worse.

The second point concerns the differentials, a point which has been made ad nauseam. In a profession which is basically female in content, it is of crucial importance that there should be an extremely attractive career structure. This is much more important in a predominantly female profession than it is in a predominantly male profession. I agree 100 per cent. with the staff side that there ought to be a sufficiently high top salary to allow for a proper career scale below it. A group matron, who will be called the Group Nursing Officer Grade 10 under the new structure, and who could be responsible for 10 to 15 hospitals, with, perhaps 2,500 to 3,000 patients, plus hundreds of staff, will get less than £3,000 a year. It is outrageous that this has lasted so long, because this is what is to be, not what is. As there are 200 grades below that, this is not a career structure.

The facts and figures now coming out under the Companies Act show that top industrialists are getting £20,000, £30,000, £40,000 to £50,000 a year. A good professional footballer gets more than two or three times what a matron of a group of hospitals will get. The B.O.A.C. pilots have been mentioned. They are asking for an increase of £4,000 to £5,000 a year on top of the present £6,000 to £7,000 a year. The argument is that the safety of hundreds of lives is in their hands day after day. What do we think a matron has in her charge? If a B.O.A.C. pilot is striking for that kind of salary, how much more so have these people the right to be militant about their position?

The Report speaks of the increasing importance which must be attached in the hospital service to the employment of more and more part-timers. Much of the wastage of nurses, though a smaller proportion than many people think is due to nurses getting married and leaving. Often they want to return. I have personal experience of this from my own wife and daughter. Nurses trying to get back into hospitals just cannot get the kind of hours that suit them domestically.

The days have gone when the nursing profession was manned by spinsters and people who had missed out for one reason or another. It is a profession which will be manned by people who are married, who have brought their families up, and who want to give service to the community. This is a vast untapped source of public service which we should strain every nerve to bring back. Hospital management must be much more flexible. Instructions should go out to hospitals to be more flexible in producing sufficiently attractive terms for these people to come back.

The Prices and Incomes Board and my hon. Friend the Member for Mother-well have done an extremely good service in focusing public atention on a highly admired profession, which gets more praise than any other profession. We give it everything but cash.

5.40 p.m.

Dame Irene Ward (Tynemouth)

Like every hon. Member in the House, I am grateful to the hon. Member for Mother-well (Mr. Lawson) for instituting this very important debate. I can hardly remember a debate dealing with a tremendous number of detailed matters concerned with the profession in which there has been so much unanimity on both sides of the House and so much emphasis on what is required to move forward into modern life with our nursing services. I imagine that the Ministers concerned will also be extremely gratified that they have so much material which is in harmony on which to work when they can find time to get down to the new organisation.

I wish to make an observation about productivity in relation to prices and incomes and the nursing profession. Having fairly recently spent some months in hospital, I think it hardly possible to talk about increased productivity in relation to the nursing profession because those engaged in the profession have not a single section of unoccupied time. What worried me when I was in hospital was the calls which the matron, doctors, and sisters had to make on the nursing profession, very often when the nurses were not in a fit state of health to offer the work they were required to do. The way in which it was done, their cheerfulness when they ought to have been in bed being nursed rather than nursing patients, made one wonder whether in all this general discussion any emphasis should be laid on increased productivity.

I am sure that in hospital management there is room for better administration, but there is very little room indeed for increased productivity in the nursing profession. I should not like to think that all the betterments required in the nursing service would have to depend on increased productivity as laid down by the Prices and Incomes Board, because it would be quite impossible and impracticable in that case to achieve them.

All the main points have been adequately covered and many hon. Members have spoken from personal experience. I do not wish to waste the time of the House re-emphasising those points. It causes grave anxiety to me and, I am sure, to many hon. Members, that the Prices and Incomes Board, which is well geared to certain jobs it has to do and certain investigations it has to make within a sphere in which it is competent, should assure that it knows very much about the grass roots of hospital administration. Someone has to say this. I do not want always to be put into the position of having to criticise those who are trying to carry out very difficult jobs for the nation, but I do not think the Prices and Incomes Board, as my right hon. Friend the Member for Reigate (Sir J. Vaughan-Morgan) brought out so well, was competent to make some of its observations.

Many of the observations made by the Board were just plain stupid. The Board did not have the knowledge or experience to make observations. I hope that in the use made of the Prices and Incomes Board we shall not have repetitions of very glorious and competent people thinking that they can make observations which the House has to follow on all sorts of professions and industries for which they have not the experience to offer any adequate opinion. I happen to have the privilege of being a vice-president—and a president in my region —of the Royal College of Nursing. I know a great deal of the way in which it has tried to work, what it requires and thinks necessary to establish a first-class nursing service, which it has tried to do throughout the years—not always with the support which it ought to have received from any Government.

I do not think my Government paid nearly enough attention to what was said by the professional nursing organisation. I am always a little chary in talking about Whitley Councils because I do not know enough about these matters, but we should remember when we talk about what goes on in Whitley Councils that the management side take their directive from the Minister. If one has read, as I have, a great deal of the evidence and discussions between the management side and the staff side and those detailed to speak for the staff side in the nursing profession, one knows that it is usual for Ministers—Conservative as well as Socialist— to adopt a very bland expression in answering Questions and debates in the House. I have had a lot of experience with my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell). We did not see eye-to-eye and I do not suppose we ever will, but there is not the slightest doubt that a great many of the difficulties which the nursing profession has experienced since the establishment of the Health Service have been due to instructions given by or at Ministerial level to the management side.

I am not certain that the management side of the Whitley Council is really competent to adjudicate, advise or direct or stonewall on the requests put forward by the staff side. I do not say that they are not very competent civil servants, but they may not be competent in knowing what is necessary for the nursing profession. Ministers of the Crown never get down to the grass roots when they issue instructions and the management side cannot give them the knowledge. They cannot give anything away unless they have the support of the Minister. I do not believe Ministers, any Ministers, have been as interested in the nursing profession because they knew with what a good section of the community they were working and that they would not have nearly as much political trouble with them as from doctors, dentists and various royal colleges. The management side was given its instructions, and one could never move it.

I hope that the Government will take into account the unanimity of views expressed this afternoon and realise that we want fair and just action. We do not want the Prices and Incomes Board or Ministers behind the scenes giving the Whitley Councils their instructions, which never see the light of day in the House. The Executive has so much power that back benchers feeling passionately on the matter, as we all do, can hardly break through the sound barrier. Therefore, I hope that the Ministers will find it easy to make their case to the Treasury.

I return to the awful point that one can never argue with the Treasury. I am very pleased that a very nice tribute was paid to the Minister in one of the Sunday newspapers, which said that he really minded about the matter. I am sure that he does, but does the Chancellor of the Exchequer know anything about it? Does he know enough to pay attention to what the Minister of Health tries to get from him for something on which the House feels strongly?

So we return to the old argument that the Executive takes the power, and the Executive here is the Treasury. The Minister, who may be boiling hot inside for all I know, and may disagree with the Prices and Incomes Board, can at any rate give better instructions to the Whitley Council. But he must take directions from the Chancellor.

I hope that the Ministers will take note that the House is unanimous, and if the nurses cannot bring sufficient pressure to bear I hope that both sides of the House will ensure that whatever the Minister thinks right and just is done. I hope that he will not have to back-pedal, but that if he has to do so the House will somehow or other be able to say what it wishes to the Chancellor.

We have had a very interesting debate and I look forward to specific proposals that are practical, fair and just resulting from it for this great profession in which we are all so interested.

5.54 p.m.

Mr. William Molloy (Ealing, North)

We have just listened to an enjoyable speech by the hon. Member for Tyne-mouth (Dame Irene Ward), but it did not do much to enhance the cause of the nurses. The hon. Lady was greatly in error in trying to lump the Whitley Council system, which may not operate perfectly for the nurses, with other Departments of State. I speak from experience as a former departmental staff side chairman, I could spend a great deal of time telling the House what was wrong with the Whitley Council system but I do not believe that even under a Tory administration the staff side members of Whitley Councils were such simpering sycophants as the hon. Lady tried to say that they were in taking directions from their Ministers.

I now turn to the debate. I was interested by the comments of the hon. Member for Birmingham, Edgbaston (Mrs. Knight), who made a very vigorous speech on behalf of the nurses. It is a great pity that she was not in the House during the period from 1948 to 1964. For, as she rightly said, for 20 years nothing much was done for the nurses on the question of pay.

Mrs. Knight

What I said was that the Prices and Incomes Board's Report was the first report in depth after a 20-year period. I was not criticising the fact that it was the first. I was saying that after all that waiting it was a disappointing report.

Mr. Molloy

If we go back further than that, the fact that nothing at all was produced is much more disappointing. I was going to say that I hoped that the hon. Lady will show her very vigorous speech to the right hon. and learned Member for Wirral (Mr. Selwyn Lloyd), who did so much to impede, denigrate and down-grade the nursing profession.

I suppose that it is inevitable that in a debate such as this many of the points one would like to raise are already covered, particularly when one speaks late in the debate. Much of what I should like to have said, and perhaps said more forcibly, has been said by other hon. Members on both sides of the House. We are all grateful to my hon. Friend the Member for Motherwell (Mr. Lawson) for providing us with this opportunity to state the case for the nursing profession this afternoon. Because so many specific recommendations have been made, I wish to speak generally on the nursing profession and to try to underline, that, for far too long it has been brutally exploited.

I am sick and tired of people telling me that a girl must have a sense of vocation to be a nurse, and be miserably treated, underpaid, and the subject of very severe discipline; but that a girl does not need a sense of vocation to be a model earning several thousands of pounds a year, to look after horses or to be a kennel maid, with better conditions and better pay. She must have a sense of vocation only to be a nurse, when she is responsible for making a contribution to people's comfort when they are sick in hospital, and for this she is not expected to have the same kind of remuneration as those who exhibit dresses, look after greyhounds or look after horses. That is the sort of thing that goes on in Great Britain today, and has been going on for the past half century.

To a certain degree I could agree with my hon. Friend the Member for Mother-well when he said that it is necessary to have a higher standard of girl entering the nursing profession. But I take the view that any young girl in the nursing profession today has already achieved a high degree of responsibility to her fellow human beings. I am not particularly concerned with whether she can cube a certain number or whether her syntax is absolutely perfect when she writes. We are reaching a situation in this country where before one is allowed to answer the telephone an employer will want to know whether one has five or six O-level certificates. We are carrying the ridiculous argument of this form of education much too far, though there must at some time be an examination or test, of course. In one part of the Report the Board calls for lowering the age of entry, but it is not prepared to do anything or suggest anything which might enhance the status of the future nurse at the other end of the scale. There is something wrong in its argument.

I do not believe that we should all get young women—it is mainly a profession of young women—to become nurses by trying almost to blackmail them, taking advantage of their conscience, suggesting that because they want to serve the community in that magnificent way there is something not very nice about having a good salary or proper accommodation for so doing. This is what we have done for far too long.

As a qualification for entry into the profession, we want not merely proof by examination of a certain level of intelligence but a combination of level of intelligence with the right personality and sincerity. It would be worth the nation's trouble if we devised a scheme by which a young woman wishing to enter nursing who had not, on the face of it, the neces- sary number of O-level passes could have a detailed examination of her work at school carried out and a period of interview at which it could be decided whether, notwithstanding her lack of academic qualifications, she nevertheless had the right fibre, so to speak, to make a nurse. An essential qualification for a good nurse is not merely academic success but a well-above-average love for one's fellows. This is most important, but it is something which, as I say, we have cashed in on in the past.

I deplore the attitude of mind which suggests that the standard of remuneration for nurses does not matter. The blunt truth is that, at all levels in the profession, from trainee nurse right through to matron, nurses are underpaid. The profession is underpaid because society has taken advantage of the fact that the profession is the very last one to indulge in any sort of industrial action. Society has in the past taken a mean attitude.

I have already emphasised that we have our priorities wrong here. This is not my right hon. Friend's fault. I am sure that he will agree that, if it only were possible—this is what we must work for —it would be much better both from the point of view of the State and from the point of view of nurses' remuneration if a nurse in hospital were looked upon as just as important a person as someone exhibiting fur coats or silk gowns in what I understand are called model houses.

Until we face the realities of the situation, we shall get nowhere. One hon. Member who spoke earlier—I am sorry he is not here now—described how he arrived at the frontier of understanding all that was involved in being a nurse only when he was a patient. It almost came to that. This happens far too often. People are not particularly interested in the nursing profession until the moment comes when a loved one or someone they know intimately is taken to hospital after being in an accident or being struck down by an awful disease. From that moment on, people's views of the nursing profession is elevated 1,000 per cent. In such circumstances, people say not merely that nurses are worth their weight in gold but they should be paid their weight in gold. But then, after the nurses and doctors have done their work and the loved one is restored to health at home, the great admiration and respect for the nursing profession seems to slip away.

This debate today has reminded us that we must not concern ourselves only on special occasions with the status of the nursing profession. Not just when disaster befalls someone whom we love, a member of the family or someone whom we know well, but at all times we must concern ourselves with the work and status of the profession, one of the most poorly paid professions in this country.

I have heard it said that in addition to their salary nurses receive lots of odds and ends from charitable institutions and other forms of charitable subsidy. It is a fine thing, for instance, that people in the theatrical profession and the managements of theatres help whenever they can by providing tickets for young nurses to go to the theatre and other shows. That is good and to be applauded, but what is wrong is that such generosity is used sometimes as an argument for asserting that nurses should not have better pay.

I know that other right hon. and hon. Members wish to speak, apart from the two Front Bench speakers, so I shall curtail savagely other parts of my speech. There are, however, one or two other matters which I wish to raise. I have tried to find a reference to the question of discipline in the Report of the Prices and Incomes Board, but I have not come across it yet, though it may well be there. I welcome the transformation which is taking place in many hospitals where there is now a more intelligent form of discipline. This is coming about because of the new attitude taken especially by some of our brilliant younger matrons. The concept of nursing as a form of military profession seems to be passing, and this is all to the good. However, the improvement is by no means general, and it should be encouraged wherever possible.

In a well-known teaching hospital not 100 miles from here, which is matroned, if I may use that term, by an excellent young matron, the staff not only admire their matron but they have a love for her because of the way in which she concerns herself to turn them out as first-class nurses while at the same time not making them subject to a hide-bound and ridiculous system of discipline. This is another aspect of progress which ought to be fostered.

All the young people beginning in this magnificent profession are equivalent in status to other students. We hear protests today from students in our universities who want more say in the way they are managed and their universities are run. There is something to be said for taking nurses more into consideration when the management of their profession is discussed. I do not mean that nurses should say how a hospital ought to be run—that would be absurd—but I believe that we should take cognisance in depth of the views of nurses, not just through their trade unions or through the Whitley Council but, perhaps, through groups of nurses themselves throughout the country. This would be a worth-while exercise, an exercise not merely for the benefit of the profession itself but for the benefit of the whole country.

The debate has been excellent. It has been worth-while not merely for nurses, for staff nurses, for matrons, for district nurses, for the whole body of the nursing profession, but also for the general public. The probability is that at one time or another each of us or someone near us will be in hospital. Therefore, it means that from the debate and the Report will flow an improvement in the status of nurses from the trainee up to the matron, that we shall get a better form of remuneration for nurses and a better organisation for the nursing profession, and what is more, a happier nursing profession, it must follow that these benefits will not stop at the nursing profession but will find expression throughout the population when from time to time people have to go into hospital.

Notwithstanding the Report, I still believe that there is a great deal to be done to uplift the dignity and status of the nursing profession. Even if some of the Report were implemented tomorrow, it is shameful to have to acknowledge that the manner in which we treat our nurses is almost a hypocrisy within our democracy, and something must be done about it. I say to the nurses: "Unite. You have nothing to lose but the meanness accorded to you in your magnificent profession."

I would add that my right hon. Friend the Minister of Health has probably done more in these four years than any of his predecessors in the previous 20, and this is acknowledged in the nursing profession. The tragedy is that if the Minister and the Government had not been concerned about the National Health Service and the nursing profession, things would have gone on as they were before and nothing much would have been said. But my right hon. Friend has done a magnificent job for the nursing profession and opened the eyes of its members to what they can achieve, and through helping them he has even put himself in a position of being attacked, though I know he will not mind that. Many nurses know full well and applaud what he is doing on their behalf.

I hope that the Minister will take the best of the Report and implement it and ignore the worst of it. I am sure that when he applies his nimble mind to the best of it he will make it even better. What he is doing means that we shall live happier and healthier lives, and those who go into hospital will know that they are looked after by a happy and efficient nursing profession acknowledged to be the magnificent profession that it is.

6.14 p.m.

Mr. Edward M. Taylor (Glasgow, Cathcart)

A constituent has sent me a letter saying that nurses are notoriously bad at standing up and fighting their own battles. Even if this were true, I think, after listening to the speeches today, particularly the last one, that the nurses can be convinced that if they cannot fight for themselves there are hon. Members on both sides of the House who are glad to do the job for them.

There has been a great amount of criticism of the Prices and Incomes Board's Report. My experience of its Reports is that, while we may disagree violently with the Board's conclusions and say, as my right hon. Friend the Member for Reigate (Sir J. Vaughan-Morgan) said, that some of the conclusions should not be implemented, the fact is that the information given and the lucid way in which complicated questions are presented are admirable in many cases, such as gas and electricity prices and municipal rents. We have had complicated matters presented in a very fair and balanced way. Where we disagree is on conclusions. I was surprised by the clear statement on page 8 of the Report that recruitment was not a problem in the meantime but would become one because of demographic factors in the near future.

On the question of tutor nurses, the Report has made crystal clear how urgent the problem is and how large it is in schools. It mentions that of the 44,740 students in general training, 19,000, or 44 per cent., were in schools which did not meet the General Nursing Council's recommended ratio. That ratio is not a generous one; it is one tutor to 40 students. The fact that 44 per cent. of students were at schools that did not meet that figure shows how serious the problem is.

The problem was presented in another way by the right hon. Lady the Member for Lanarkshire, North (Miss Herbison), who gave the figures for Scotland of qualified tutors. In respect of the Western region alone we see how serious the position is. The establishment of tutors is 210, but of that number 59 are not there, represented by vacant posts, and 56 are non-certificated teaching staff —not people who are not qualified, but people who do not have the special qualification for teaching. The figures for Scotland as a whole show an establishment of 410 represented by 96 vacancies and 102 full-time non-certificated teachers. So we have a situation in Scotland where about half the establishment is either not there or represented by people who are not fully qualified. We have an alarming situation.

On the subject of the career structure and the salary structure, the hon. Member for Fife, West (Mr. William Hamilton) mentioned the various allowances for special duties—geriatric duties, late duty and so on. I hope that the Government will be fully aware of the anomalies in salaries which are arising as a result of increasing allowances, as a result of raising the basic rate and as a result of not raising the top level. We have the absurd situation that a night sister's salary can be higher than that of a night superintendent because of special allowances, and a senior enrolled nurse in a geriatric hospital working at weekends can have a salary higher than a fully qualified tutor.

I am not saying that the special allowances are not justified. Of course they are. For working in geriatrics and for late working allowances are justified. But there is a real danger that these special payments will undermine the basic differentials which are at the root of any career structure. This is the danger at present.

I can tell the Minister and, in particular, the Under-Secretary of State for Scotland that hon. Members on both sides of the House were glad to learn that in view of representations made by hon. Members on both sides and the Royal College of Nursing the Minister of Health has given an undertaking that the matter will be reviewed at the end of the year when the salary scales are due to be introduced. What has been said from both sides of the House will have made clear to the Minister that there is a case for such a review for nurse tutors, and I hope that the reconsideration will be carefully done and that the result will be favourable.

6.19 p.m.

Mr. Maurice Macmillan (Farnham)

I join other hon. Members in thanking the hon. Member for Motherwell (Mr. Lawson) for raising this important matter and particularly for raising a United Kingdom subject rather than a national one, though I am happy to see that Scottish Members on both sides of the House were well represented.

The pay of nurses and midwives has been a major problem for successive Governments. My hon. Friend the Member for Tynemouth (Dame Irene Ward) suggested that the Minister was rather too much in control of the management side of the Whitley Council. Perhaps I might suggest that one of the difficulties that successive Governments have faced is the ease with which the Treasury can use nurses' pay as a method of making cuts in Government spending or preventing rises in Government spending. Ministers on both sides have been attacked about this.

This is one of the reasons why it is important that the … failure to give sufficient recognition to the higher levels of qualification and skill … should not dissuade the Minister from not accepting this part of the Report. The Board indicated that it was necessary to pay market rates for skills in nursing as well as for other professions, but, unfortunately, it did not sustain that principle in its recommendations. That is why the Report has had such a bad reception, not only from the profession, but from both sides of the House. Here I must declare an interest, perhaps not one in a technical sense, but in that I have a natural bias towards the staff side as publisher of the Nursing Times.

I want to make two main points, both of which have been argued in different aspects. The first concerns the differentials; the second concerns the special aspects demonstrated by the position of the sister-tutors and their effect on nursing education. I want to deal with them in relation to the hospital service, the nursing staff and the difficulties which, in some ways, have been slightly exacerbated by some of the provisions of the Report.

The structure of nurses' pay has always had many anomalies. Successive Governments have had difficulty in trying to equate the justice of the case and the needs of recruiting with the demands of the Treasury. The anomalies have been at their worst in two forms of hospital service: first, the specialist nursing and, secondly, the professions ancillary to nursing and other employees of the hospital service, such as pharmacists and physiotherapists. I shall return to this aspect later.

There has always been a great recruiting problem. One of the difficulties which the profession has had to face is that it is not open to it to take industrial action. It cannot strike. It cannot even go slow. Student nurses cannot even change their job without, in effect, leaving the profession and this makes them an obvious target for exploitation by the State and the community as a whole.

The combination of these factors has led the Board in its Report to penalise the top end of the profession. Up to now, the anomalies at the top have had no great result on women staying on or leaving the profession. This is changing and, because the Report creates at the top end more anomalies than it removes, I suspect that the rate of change and the rate of leaving the profession will accelerate.

The Board suggests raising the floor, and quite rightly, but it has not suggested raising the ceiling. There is a squeeze between Grade 1 and Grade 9, leaving aside Grade 10 for the moment. I need not develop that point, as it has been made clear by other hon. Members. The pressure between the top end of Grade 1 and the bottom end of Grade 9 is particularly great.

I shall not weary the House with percentage figures, but they indicate that the differential between the most highly-paid people in Grade 1 and the most lowly paid in Grade 9 is too small. This has had a consequential effect of squeezing up the differentials in the other grades, particularly reflected in the lack of improvement in the position of sister-tutors, among others, in Grades 6 and 7. This, of course, applies over the whole range, as many hon. Members have argued.

The second aspect turns on the whole question of the position of the chief nursing officer in Grade 10. The Board has failed to comprehend two factors. The first is the nature of the post and the second is the implications that its nature should carry in relation to salary. In effect, the position of chief nursing officer Grade 10 is a "Salmon" creation. It is a new post of a new type and shape. It is not merely an upgrading of existing posts and it is not strictly comparable to any job now existing in the hospital service. It is not comparable entirely, for example, with the job of matron, because it includes, to an extent which the job of matron does not, planning for the future as well as supervising day to day functions in a group of hospitals. The overall responsibility for a group of hospitals is very great. It is not really comparable to any present position and the tendency of the Report to compare it with hospital administrators is a wrong conclusion to draw.

A chief nursing officer will normally be dealing with 1,600 staff and a budget of about £1½ million. I tried to find out what women in comparable jobs in industry are likely to be paid. Messrs. J. Lyons and Company would expect to pay a woman between £4,000 and £5,000 a year for a job of this magnitude, and I am informed that Messrs. Marks and Spencer, in a relatively small store where the manageress was working as No. 2 to a man, would expect to pay her about £3,000 a year. Even that would be slightly above the top level of a chief nursing officer, who will have far greater responsibilities.

Allied to this is the question of training. The whole future of nursing education and training is likely to be adversely affected by some of the Report's recommendations. First, there is the obvious reason of the too low pay for sister tutors; secondly, there is the less obvious reason that the Report tends to exaggerate the position of a student nurse as simply an employee of the hospital service, as a pair of hands—although it is harder on the legs and feet. This is also bound to affect recruitment, because if student nurses are to be paid as apprentices they must receive the proper education and training, because that is the only factor which makes the low pay for student nurses, or of apprentices in any industry, tolerable.

The requirements of training mean that there is no protection and no protest open to student nurses except that of leaving their profession. Once they are trained, they can get a new job outside the hospital service, and even a new job within the public service without having to go into private nursing. But the student nurse cannot, and it is very small wonder that wastage is now about 36 per cent. This cannot be stopped simply by improving the level of pay of student nurses.

The standard of their training and education, prospects for future pay, the differential for the skilled person and the career structure are far more important to these very young girls than their actual pay at the moment. But if those other factors are not right, they will rightly expect the rate for the job. In other words, they have to be paid in training or in cash, but not by an inadequate mixture of both.

I am not concerned to argue that the reward for the sister tutor is miserable; that is obvious. If it was not obvious before the debate, the remarks of the right hon. Lady the Member for Lanarkshire, North (Miss Herbison) and of my hon. Friend the Member for Moray and Nairn (Mr. G. Campbell) have made it obvious. We have already seen that there is a drifting away from the hospital service in some of the ancillary professions. Now the tendency to drift away, even to other parts of the public service, is well established.

As my hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) said, the sister tutor can get £600 or £700 a year more in a training college than in a hospital, and in these circumstances the factor of vocation and the desire to serve the public is not altered, because a service to education obviously has to be carried out and can be performed as well in a training college as in a hospital.

Even if the Minister cannot accept some of the other arguments put to him, I hope that he will be able to have second thoughts about this aspect of the Report. These factors affect the whole future of the service within the National Health Service, the shortage of nurses and the right of people, even if they are serving their fellow man and even if they have a vocation for it, to be properly paid and to expect proper prospects of promotion and reward.

This brings me to a few general considerations which I want to raise. The objections to the Report which have already been expressed show up certain other parts which can be criticised, although I, too, find a great deal to praise, and the Minister must not think that we do not find anything to praise if we spend the limited time available in what I hope is constructive criticism. Reading through the Report, I felt that at the back of its mind the Board had the thought that one of its most important tasks was the factor of keeping down Health Service costs and that it should do so in a way which would enable the nursing service to carry a disproportionate burden of any economies.

It is a common fallacy of all prices and incomes policies that keeping the rate of pay below the market level automatically reduces or keeps down the labour cost of the operation concerned, regardless of any other considerations, such as efficiency of management, the most efficient use of labour, and so on. The Report ignored far too much the other demands, both inside and outside the public service, on nurses and on other people with the skills and integrity required for the nursing profession, especially at the top levels. The Report tended to underrate the need for married women at high levels of employment within the Service and, as one hon. Member said, the fact that the youngish, single, dedicated woman just does not exist any more, and it took very little account of the fiscal consequences of all this.

I am sure that hon. Members will appreciate that various adjustments could be made to the tax position of both married and single women which would enable them to discharge their duties at the top level of a profession, such as nursing, far more readily and far more easily. As the Board went wide of simply the pay and conditions of nurses, it could have strayed as far as to consider that type of constructive suggestion.

Perhaps the Board did not need to take all these considerations into account, but the Minister must, for there will otherwise be a great danger that the failure to get pay conditions and structure right at the top will be very damaging not so much now as in the future when the Minister develops his plans for the grouping of hospitals in the development of the district general hospital and the grouping of nurses' training. The more we try to centralise and to economise in administration, whether on the Porritt line or not, the more important it will be to get right the structure of employment within the different sections of a service.

Where, in the past, these things could be dealt with on a relatively small scale, with room for variations to take greater account of factors which did not have a very wide application, what the Minister is now trying to do—and I am not saying that he is wrong—is to establish this type of organisation on a national basis and to carry that through with a unified Ministry with the full sanction of Government behind it.

In these circumstances, it is up to the Minister to pay a little more attention than the Board did to the details and to the possibilities for the future. I am not trying to criticise the Board for having gone well wide of its terms of reference, but merely saying that it ignored some of the factors which the Minister has not ignored in his Green Paper and of which, I hope, he will take account when he considers the recommendations of the Report.

We have seen all the dangers. We have seen the psychiatric social workers being tempted away from the hospital service to local government service. We have seen radiographers, the hospital pharmacists, the physiotherapists and many more leaving, and now we shall see the sister tutors leaving and perhaps some other high grade people not coming into the service. I will not ask the Minister to accept that all this stems from the sort of approach which the Board tends to take to these problems, for opinions differ on the value of that aproach, and I am perfectly willing for him to disguise the need to pay the market rate if he wishes to quote comparability, which is merely saying the same thing in a different way. But it is essential to have the differential between Grade 1 and Grade 9 wide and every time the level of pay is raised, as the cost of living goes up, to carry the increase through to keep the differential up to Grade 9.

I hope that the Minister will appreciate that by putting up the salary of Grade 10, he would not be creating a major problem for hospital administrators and that if the whole structure started at a higher level, differentials would be much easier to maintain half way down. Above all, I hope that he will bear in mind that the hospital service is competing for highly qualified men and women whose sense of vocation and dedication can be fulfilled outside the service. The future of the service, as well as justice, means that they must be able to get their true reward by still working within it.

6.40 p.m.

The Minister of Health (Mr. Kenneth Robinson)

I would like to join with other hon. Members in congratulating my hon. Friend the Member for Motherwell (Mr. Lawson), not only on initiating this debate, but also upon his constructive contribution to it. The debate has been constructive in the way that one would expect of a debate dealing with the affairs of a profession to whom the whole country owes so much. I will do my best, in the time available, to answer some of the points, but it might be helpful if I say a little about the background of the reference of nurses pay to the Prices and Incomes Board.

In 1965, the Nurses and Midwives Whitley Council reached a settlement, giving increases in pay averaging just over 11 per cent. which were to last for two years, to the end of June 1967. This settlement represented a substantial improvement, and was in marked contrast to the difficulties which have attended nurses' pay claims under the previous Conservative Administration. My hon. Friend the Member for Fife, West (Mr. William Hamilton) and my right hon. Friend the Member for Lanarkshire, North (Miss Herbison) reminded the House that nurses were the first victims of an attempt in 1961 to hold pay increases in the public sector to 2½ per cent.—an action which led to a difficult and acrimonious period of negotiation, culminating in arbitrations in successive years. When the 1965 settlement was due to expire, the staff side of the Whitley Council submitted a general pay claim for very substantial increases, and there were other outstanding claims on overtime, hours of work and special duty payments.

Following a joint recommendation from both sides of the Whitley Council, the Government referred nurses' pay and related conditions of service to the Prices and Incomes Board on 29th June last year. As the House knows, the Report was published on 28th March of this year. The Government accepted that the pay proposals contained were consistent with incomes policy and commended them to the Whitley Council for negotiation. The effect of the recommendations on pay was to give a general salary increase of 9 per cent., with 14 per cent. increases at certain points, to be paid in two stages, 4 per cent. back-dated from October, 1967, and the remainder from 1st January, 1969.

It is only right to make the point that at a time of a nil norm and a 3½ per cent. ceiling, both the Board and the Government were clearly recognising that exceptional treatment for nurses was called for within the terms of an income policy. Taking together the effect of these recommendations and the previous settlement, the pay of nurses will be very substantially higher on 1st January next than it was three years ago. This progress has been made at a time of considerable economic difficulty. The hon. Member for Farnham (Mr. Maurice Macmillan) suggested that somehow the Report aimed at reducing the costs of the N.H.S. Adding £44 million extra to the salary bill seems an odd way of going about it.

The Whitley Council has already made substantial progress in its discussions. It has reached agreement on the general pay increase. The Board made other recommendations over and above these general increases in salary, and these too, have been engaging the attention of the Whitley Council. The Council has reached agreement, operative from 1st April, on the recommendation of an increase in the psychiatric "lead" for nursing staff engaged in psychiatric nursing and the introduction of a similar geriatric "lead" for those engaged in this type of nursing. I am grateful to my hon. Friend the Member for Huddersfield, West (Mr. Lomas) for mentioning that. There are other recommendations which have been agreed by the Council, including the extension of overtime pay to certain grades and an increase in the annual leave entitlement of certain local authority staff.

There has been considerable criticism from the profession on what the Board said on nursing education. This theme has occurred in a number of speeches on both sides of the House. I cannot accept that the Board took an unfair view of the importance of nurse training, nor that it was not equipped to deal with it. The terms of reference of the Board enabled it to range very widely, and it was asked to look at related conditions as well as pay. The profession, rather too easily, took offence at this. I agree that the Board might have said more about the functions of nurse tutors, but it said a great deal about nursing education and improvements which could be made.

My Department will be discussing these recommendations with the hospital service and the General Nursing Council. I had a meeting recently with representatives of nursing education from the Royal College of Nursing and I believe that what I said then went some way towards relieving some, at any rate, of their anxieties on this score.

There has been criticism of the pay of nurse tutors. Some people have taken the view that their pay ought to be linked with that of other categories of teachers rather than with other categories of nurses. This was implicit in what my right hon. Friend the Member for Lanarkshire, North and my hon. Friend the Member for Motherwell said. The Whitley Council has always taken the view, which I share, that links with other nursing staff are more important. In recommending the top scale of Grade 7 for the registered nurse tutor, the Board was giving her a larger than average increase.

Taking together the effect of the Salmon Committee's recommendations and the Board's Report, there will be a new career structure with three grades instead of two, and the highest salary open to nurse tutors in the highest posts, in Grade 9, will be 60 per cent. higher than the highest salary provided for principal tutors in the 1965 Whitley Agreement. I am fully conscious of the importance of nurse education and of the scope for improvement. I set out my views on this to hospital authorities last year.

Age of entry is primarily a matter for the General Nursing Council, but for some years I have made no secret of my view that it might be lowered. In this, I part company with my hon. Friend the Member for Motherwell, and I think with the general view of the Royal College of Nursing. This recommendation will be discussed with the General Nursing Council.

The number of qualified teaching staff needs to be increased. As the Board said, their uneven distribution accentuates the problems arising from their general shortage. My Department is studying, with the General Nursing Council and the Royal College, the whole question of the requirements and functions of tutors.

The impression was given in a number of speeches that the number of registered nurse tutors is declining. This is not so. The numbers are increasing slightly. I agree that the average age is higher than we should like to see it. The salary decision follows the general view of the Whitley Council, that comparisons should be with other nurses. One hon. Member gave an example of a nurse tutor who went to a technical college for a considerably higher salary.

All I can say is that if there is this movement, there must be another in the opposite direction, to balance out the numbers, so that we are managing to achieve this small increase, year by year. The introduction of the scheme of nursing administration, recommended by the Salmon Committee should do a great deal to improve the status of senior nurses, as well as providing better management and an improved service. I will not repeat what the hon. Member for Farnham said about the duties of a chief nursing officer, but this is a very significant step forward.

The Salmon Committee recommended that the new structure should be tried out over a period in a series of carefully chosen pilot schemes and then generally introduced over a period of years. Accordingly, 17 hospital groups in England and Wales have so far been selected for pilot schemes and others are under consideration. The selection involved extensive consultations and visiting of the hospitals by a team from my Department to ensure that the group was suitable and that everybody understood the implications. I understand that, in general, this method and procedure has commended itself to the hospital service and the nursing profession, but we are reaching the stage at which wider implementation must be considered.

However, this is not a simple question of introducing new grades. It is a matter of defining new rôles, setting out clear lines of authority and ensuring that communications are free from obstruction. The Prices and Incomes Board recommended that a deadline should be set for the complete implementation of the Salmon recommendations. I am considering this, and I am consulting regional hospital boards on what they would consider practicable.

I turn to the question of pay. There has been considerable debate on the recommended salary of the chief nursing officer. The staff side made a claim for scales of pay with £4,500 as the maximum of the higest scale. The Board considered it and recommended scales with a maximum of £2,950. I am well aware of the disappointment felt in the profession at this recommendation, but the Board took evidence from all the interested parties, and I have no doubt that the staff side and the professional interests consulted put their point of view very forcefully. The Board reached its conclusions after careful consideration and in the light of the incomes policy, and the Government have no reason to question its conclusions. I think that I am right in saying that the Board did not take evidence from the Department on this point.

My hon. Friend the Member for Motherwell took exception to the increases in board and lodging charges for resident nurses which accompanied the pay increases. I think that there is some misunderstanding here. These increases and their operative date were very clearly recommended by the Board. But this is a question not only of the level of nurses' net pay, but of fairness as between resident and non-resident staff. Board and lodging charges do not represent and never have represented the full cost of providing these services. In other words, resident staff are subsidised. To freeze charges when costs have risen would be to increase the amount of subsidy, so that, in practical terms, resident staff would receive more real benefit than nonresident staff, which I think would be unfair.

There is no doubt that in the past highly subsidised residence has had a depressing effect on remuneration. The Board recognised this and recommended that a start should be made on costing the various services which are provided with a view to a realistic charging system. This will not be easy, but I am considering how the necessary information can be collected.

My hon. Friend the Member for Motherwell suggested that great weight should be given to the Report. The right hon. Member for Reigate (Sir J. Vaughan-Morgan) and the hon. Lady the Member for Tynemouth (Dame Irene Ward) took a rather different view and said that less weight should be given to it. A good deal was made of the alleged shift in the structure of the nursing profession in the hospital service in the direction of the less skilled. But there has been a steady increase in the number of more skilled nursing staff, although admittedly a higher rate of increase in the number of less skilled.

There are two ways of looking at these statistics. One is the way in which my hon. Friend the Member for Motherwell looked at them. The other is this. We have managed through the roll to tap an extra source of staff who were either unwilling to undergo a three-year training, or who perhaps lacked the necessary educational requirements. Certainly, this is not a development which the Royal College of Nursing regrets. I have here its comments on the Prices and Incomes Board's Report, in which it says that This requirement pre-supposed a reduction in the number admitted to training for the Register with a corresponding increase in those admitted to training for the Roll. …. The Council now reaffirms this as a policy objective. The State enrolled nurse plays a large part and will play an increasingly large part in the work of our hospital service.

My hon. Friend the Member for Fife, West referred to the Board's recommendations relating to part-time staff. The service is already independent to a very appreciable extent on the services of married women working part-time. The importance of this source of recruitment and the need to try to make the best use of the hours that part-timers can offer have been repeatedly drawn to the attention of hospitals, and I have, on a number of occasions, stressed that much of the further increase in nursing staff must come from this source.

Although still more must be done, I think that the performance so far has been quite creditable. The number of part-time nurses has risen from nearly 36,000 to over 48,600—that is, in terms of whole-time equivalents—and part-time midwives by 50 per cent., from 1,200 to 1,800. If one excluded trainee nurses and midwives, almost all of whom are on full-time courses, the proportion of part-time staff becomes nearly one-third of the total nursing staff of our hospitals.

There has been reference to the split shift system. We shall consider this. The suggestion was that it made for bad staff relations without any gain in staff and efficiency. This may often be true, but not invariably. I gather that sometimes nurses find advantage in working split shifts—for example, where a hospital is near a large shopping centre.

Mr. Laurence Pavitt (Willesden, West)

Would my right hon. Friend consider the situation in which a nurse starts a split duty at 7.30 in the morning and finishes at 8 p.m. and gets no extra pay for it, whereas stokers in the same hospital do? When he considers the split shift system, will he consider this point?

Mr. Robinson

I am sure that that is a matter which the Whitley Council will look at in the course of its consideration of the outstanding recommendations in the Report.

I can understand that there is some disquiet in the nursing profession. I know that nurses have been disturbed by some passages in the Board's Report, and that they are worried about the status of chief nursing officers and matrons and about standards and quality of training. Where the Salmon management structure is introduced, new rôles must be defined with some changes of attitude. I accept that that in itself tends to lead to uncertainty. But I do not think that we should exaggerate this disquiet or the justification for it. The Salmon Report was a major step forward in the organisation of hospital nursing services. I think that, on the whole, it is generally accepted that my Department acted wisely and with care in the way in which the pilot schemes were introduced.

I can give the assurance that I shall not act hastily on the Board's recommendations on training and management which have disturbed the profession. I do not think that hon. Members can accuse me or my Department of any lack of interest in the well-being of the nursing profession. There will certainly be proper consultation with the service and with the profession about all these recommendations.

I think that we must accept the independent findings of the Board on pay up to 1970. But the staff side will see that it is for the nurses to establish their new position in the structure of management. Their chief nursing officer posts are new, and until they are properly established the staff side perhaps cannot fully develop its arguments. But the Government cannot accept that in the recommendations on pay at the higher levels in the nursing profession at present, and in the context of incomes policy, there are deficiencies in the Board's Report which need to be rectified. For that reason, I feel unable—

It being Seven o'clock, the Proceedings on the Motion lapsed, pursuant to Standing Order No. 5(6) (Precedence of Government Business).